1
|
Nielsen MK, Nielsen AW, Donskov AO, Hansen IT, Nielsen BD, Mørk C, Hauge EM, Keller KK. Taper versus discontinuation of tocilizumab in patients with giant cell arteritis: Real-world experience from a tertiary center. Semin Arthritis Rheum 2024; 68:152508. [PMID: 38981187 DOI: 10.1016/j.semarthrit.2024.152508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/11/2024]
Abstract
INTRODUCTION Following the approval of tocilizumab (TCZ) for giant cell arteritis (GCA), recent studies have shown a high relapse frequency after abrupt discontinuation of TCZ. However, a thorough exploration of TCZ tapering compared to abrupt discontinuation has never been undertaken. Likewise, adverse events have only been scarcely investigated in routine care. This study aimed to compare the incidence of relapses in GCA patients undergoing TCZ tapering compared to abrupt discontinuation. METHODS We performed a single-center retrospective cohort study from 2012 to 2022. Data from GCA patients treated with TCZ was obtained from the Electronic Patients Record. Relapse-free survival is reported in Kaplan-Meier plots and tapering versus abrupt discontinuation were compared using a Wilcoxon-Brewlos-Gehan test. RESULTS We included 155 patients receiving TCZ treatment for GCA, of which 104 discontinued TCZ. Among the 104 patients discontinuing TCZ, 42 (40 %) experienced a relapse within the first year. A total of 57 patients underwent taper with 6/38 (16 %) and 2/19 (11 %) relapsing while receiving TCZ every second or third week, respectively. In comparison, 59 patients underwent abrupt discontinuation with 27 (46 %) relapsing during follow-up. The patients undergoing abrupt TCZ discontinuation demonstrated a significantly shorter time to relapse compared to all tapered patients (p = 0.02) as well as patients tapered from weekly TCZ treatment to every second week (p < 0.01). Furthermore, 15 % of patients discontinued TCZ due to adverse events. CONCLUSION This is the first study indicating that TCZ taper induced longer relapse-free survival than abrupt discontinuation, implying that taper may be favored over discontinuation in patients with GCA.
Collapse
Affiliation(s)
- Marc K Nielsen
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark.
| | - Andreas W Nielsen
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus, Denmark
| | - Agnete O Donskov
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark
| | - Ib T Hansen
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus, Denmark
| | - Berit D Nielsen
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus, Denmark; Horsens Regional Hospital, Department of Internal Medicine, Horsens, Denmark
| | - Christoffer Mørk
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark
| | - Ellen M Hauge
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus, Denmark
| | - Kresten K Keller
- Aarhus University Hospital, Department of Rheumatology, Aarhus, Denmark; Aarhus University, Department of Clinical Medicine, Aarhus, Denmark
| |
Collapse
|
2
|
González-García A, Fabregate M, Serralta G, de Miguel Campo B, Noblejas-Mozo A, Robles-Marhuenda Á. The utility of 18F-FDG-PET/CT in detecting extracranial large vessel vasculitis in rheumatic polymyalgia or giant cell arteritis. A systematic review and meta-analysis. Rev Clin Esp 2024; 224:445-456. [PMID: 38852739 DOI: 10.1016/j.rceng.2024.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/25/2024] [Indexed: 06/11/2024]
Abstract
OBJECTIVE Systematic review of current evidence to analyze the prevalence of extracranial large vessel vasculitis (LVV) using 18F-FDG PET/CT in patients with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA). MATERIALS AND METHODS PubMed and EMBASE were searched and the results were screened by two reviewers. Study quality was assessed using a modified version of the Newcastle-Ottawa scale. Heterogeneity between studies was assessed using the I2 statistic and the Q test. Further subgroup analyses were performed by disease type, study quality, and 18F-FDG PET/CT uptake criteria. Publication bias was assessed by funnel plot and Egger's test. RESULTS 268 publications were identified, of which 17 met the selection criteria and were included in the meta-analysis. The overall pooled prevalence of extracranial LVV by 18F-FDG PET/CT was 54.5% [95% CI: 42.6%-66.1%]. In patients with GCA the prevalence was significantly higher than in patients with PMR (60.1% vs. 41.8%, P = 0.006). Likewise, studies with a lower risk of bias reported a higher prevalence of extracranial LVV (61.1% vs. 46.9%; P = 0.010). No publication bias was observed. CONCLUSIONS The 18F-FDG PET/CT test may be useful in the detection of extracranial LVV, both in patients with PMR or GCA. Such involvement is more frequent in patients with GCA, and may vary depending on the quality of the studies.
Collapse
Affiliation(s)
- Andrés González-García
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain.
| | - Martín Fabregate
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, Madrid, Spain
| | - Gonzalo Serralta
- Servicio de Medicina Interna, Hospital Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
| | - Borja de Miguel Campo
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital 12 de Octubre, Madrid, Spain
| | - Ana Noblejas-Mozo
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital La Paz, Madrid, Spain
| | - Ángel Robles-Marhuenda
- Unidad de Enfermedades Autoinmunes Sistémicas, Servicio de Medicina Interna, Hospital La Paz, Madrid, Spain
| |
Collapse
|
3
|
Billet AC, Thibault T, Liozon É, De Boysson H, Perard L, Espitia O, Daumas A, De Pinho QG, Durel CA, Hot A, Bienvenu B, Humbert S, Bachmeyer C, Mainbourg S, Sené T, Devilliers H, Bailloud BD, Greigert H, Cochet A, Bonnotte B, Alberini JL, Samson M. Prognostic value of 18 FDG-PET at diagnosis and follow-up in giant cell arteritis: An observational restrospective study. Eur J Intern Med 2024; 126:69-76. [PMID: 38627183 DOI: 10.1016/j.ejim.2024.03.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES To evaluate the ability of 18FDG PET/CT, at diagnosis of giant cell arteritis (GCA) and during follow-up, to predict occurrence of relapse in large-vessel GCA (LV-GCA). METHODS We conducted a retrospective study using the French Study Group for Large-Vessel Vasculitis (GEFA) network. Data from patients with LV-GCA diagnosed by PET/CT and who had PET/CT in the following year were collected. For each PET/CT, PET vascular activity score (PETVAS) and total vascular score (TVS) were assessed, and their ability to predict the occurrence of subsequent relapse was assessed. RESULTS A total of 65 LV-GCA patients were included, of whom 55 had undergone a follow-up PET/CT 3 to 12 months after the diagnosis of GCA. Patients for whom the second PET/CT (PET2) was performed during active GCA were excluded. PETVAS and TVS decreased between PET1 and PET2 in all patients (p < 0.001). There was no correlation between vascular activity scores in PET2 and time to prednisone taper. For relapse prediction, at PET1, the AUC of the TVS and PETVAS were respectively 51.9 and 41.9 at 6 months, 55.3 and 49.7 at 1 year, 55 and 55.7 at 2 years. For PET2, the AUC were respectively 46.1 and 46.7 at 6 months, 52.1 and 48.9 at 1 year, 58.4 and 52.3 at 2 years. CONCLUSION PET vascular activity scores at diagnosis and at follow-up PET/CT performed outside a period of GCA activity do not display high performance to predict the occurrence of subsequent relapse in LV-GCA patients.
Collapse
Affiliation(s)
- Anne-Claire Billet
- Department of Internal Medicine and Clinical Immunology, Referral Center for Rare Systemic Autoimmune and Autoinflammatory Diseases (MAIS), Dijon Bourgogne University Hospital, Dijon, France
| | - Thomas Thibault
- Department of internal medicine and systemic diseases, Dijon Bourgogne University Hospital, Dijon, France
| | - Éric Liozon
- Department of Internal Medicine, University Hospital, Limoges, France
| | | | - Laurent Perard
- Department of Internal Medicine, Saint Joseph Saint Luc Hospital, Lyon, France
| | - Olivier Espitia
- Nantes University, CHU Nantes, Department of Internal and Vascular Medicine, l'institut du thorax, INSERM UMR1087/CNRS UMR 6291, Team III Vascular & Pulmonary diseases, F-44000 Nantes, France
| | - Aurélie Daumas
- Department of Internal Medicine, Geriatric and Therapeutic, La Timone, APHM, C2VN, Aix-Marseille University, France
| | | | - Cécile-Audrey Durel
- Department of Internal Medicine, Saint Joseph Saint Luc Hospital, Lyon, France
| | - Arnaud Hot
- Department of Internal Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, France
| | - Boris Bienvenu
- Department of Internal Medicine, Saint Joseph Hospital, Marseille, France
| | - Sébastien Humbert
- Department of Internal Medicine, University Hospital, Besancon, France
| | - Claude Bachmeyer
- Department of Internal Medicine, Tenon, Paris University Hospital, France
| | - Sabine Mainbourg
- Department of Internal and Vascular Medicine, South University Hospital, Hospices Civils de Lyon, France
| | - Thomas Sené
- Department of Internal Medicine, Rothschild Hospital Foundation, Paris, France
| | - Hervé Devilliers
- Department of internal medicine and systemic diseases, Dijon Bourgogne University Hospital, Dijon, France
| | | | - Hélène Greigert
- Department of Internal Medicine and Clinical Immunology, Referral Center for Rare Systemic Autoimmune and Autoinflammatory Diseases (MAIS), Dijon Bourgogne University Hospital, Dijon, France; INSERM, EFS BFC, UMR 1098, RIGHT Graft-Host-Tumor Interactions/Cellular and Genetic Engineering, Bourgogne Franche-Comté University, Dijon, France
| | - Alexandre Cochet
- Laboratoire ICMUB, CNRS UMR 6302, Université de Bourgogne, Dijon, France
| | - Bernard Bonnotte
- Department of Internal Medicine and Clinical Immunology, Referral Center for Rare Systemic Autoimmune and Autoinflammatory Diseases (MAIS), Dijon Bourgogne University Hospital, Dijon, France; INSERM, EFS BFC, UMR 1098, RIGHT Graft-Host-Tumor Interactions/Cellular and Genetic Engineering, Bourgogne Franche-Comté University, Dijon, France
| | | | - Maxime Samson
- Department of Internal Medicine and Clinical Immunology, Referral Center for Rare Systemic Autoimmune and Autoinflammatory Diseases (MAIS), Dijon Bourgogne University Hospital, Dijon, France; INSERM, EFS BFC, UMR 1098, RIGHT Graft-Host-Tumor Interactions/Cellular and Genetic Engineering, Bourgogne Franche-Comté University, Dijon, France.
| |
Collapse
|
4
|
Harigai M, Miyamae T, Hashimoto H, Umetsu K, Yamashita K, Nakaoka Y. A multicentre, large-scale, observational study of tocilizumab in patients with giant cell arteritis in Japan. Mod Rheumatol 2024; 34:775-783. [PMID: 37522620 DOI: 10.1093/mr/road074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/03/2023] [Accepted: 07/11/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVES In clinical trials, tocilizumab (TCZ) is efficacious in patients with giant cell arteritis (GCA). This study evaluated the real-world tolerability and effectiveness of TCZ in Japanese patients with GCA. METHODS In this multicentre, prospective, Phase 4, large-scale, observational study, patients with GCA (with no TCZ treatment 6 months before the study) were recruited from 71 centres across Japan. Patients received subcutaneous TCZ 162 mg weekly (observation period, 52 weeks). RESULTS Of the 117 patients [female, 70.1%; mean age, 74.2 years; mean disease duration, 1.4 years; treated for new-onset GCA, 71.8%; presence of large-vessel lesions (LVLs), 61.5%; previous immunosuppressant use, 28.2%; glucocorticoids at baseline, 95.7% (mean: 22.4 mg/day)], 38.5% reported adverse events. The most common adverse events of special interest were neutropaenia and leukopaenia (7.7%), followed by serious infection (6.0%). The relapse-free proportion was 85.0%; relapse after remission, 6.0%; and no remission, 9.0%. At the last observation, 94.2% of relapse-free patients received a concomitant glucocorticoid dose of <10 mg/day. Fatigue, headache, neck pain, and absence of LVLs were positively associated with the relapse. CONCLUSIONS TCZ was effective and well tolerated in Japanese patients with GCA and may be an effective treatment option combined with glucocorticoids.
Collapse
Affiliation(s)
- Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takako Miyamae
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Hideyuki Hashimoto
- Risk Communication Department, Drug Safety Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Kosei Umetsu
- Safety Science Department, Drug Safety Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Katsuhisa Yamashita
- Specialty Medical Science Department, Medical Affairs Division, Chugai Pharmaceutical Co., Ltd, Tokyo, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Osaka, Japan
| |
Collapse
|
5
|
Schmidt WA, Schäfer VS. Diagnosing vasculitis with ultrasound: findings and pitfalls. Ther Adv Musculoskelet Dis 2024; 16:1759720X241251742. [PMID: 38846756 PMCID: PMC11155338 DOI: 10.1177/1759720x241251742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024] Open
Abstract
Rheumatologists are increasingly utilizing ultrasound for suspected giant cell arteritis (GCA) or Takayasu arteritis (TAK). This enables direct confirmation of a suspected diagnosis within the examination room without further referrals. Rheumatologists can ask additional questions and explain findings to their patients while performing ultrasound, preferably in fast-track clinics to prevent vision loss. Vascular ultrasound for suspected vasculitis was recently integrated into rheumatology training in Germany. New European Alliance of Associations for Rheumatology recommendations prioritize ultrasound as the first imaging tool for suspected GCA and recommend it as an imaging option for suspected TAK alongside magnetic resonance imaging, positron emission tomography and computed tomography. Ultrasound is integral to the new classification criteria for GCA and TAK. Diagnosis is based on consistent clinical and ultrasound findings. Inconclusive cases require histology or additional imaging tests. Robust evidence establishes high sensitivities and specificities for ultrasound. Reliability is good among experts. Ultrasound reveals a characteristic non-compressible 'halo sign' indicating intima-media thickening (IMT) and, in acute disease, artery wall oedema. Ultrasound can further identify stenoses, occlusions and aneurysms, and IMT can be measured. In suspected GCA, ultrasound should include at least the temporal and axillary arteries bilaterally. Nearly all other arteries are accessible except the descending thoracic aorta. TAK mostly involves the common carotid and subclavian arteries. Ultrasound detects subclinical GCA in over 20% of polymyalgia rheumatica (PMR) patients without GCA symptoms. Patients with silent GCA should be treated as GCA because they experience more relapses and require higher glucocorticoid doses than PMR patients without GCA. Scores based on intima-thickness (IMT) of temporal and axillary arteries aid follow-up of GCA, particularly in trials. The IMT decreases more rapidly in temporal than in axillary arteries. Ascending aorta ultrasound helps monitor patients with extracranial GCA for the development of aneurysms. Experienced sonologists can easily identify pitfalls, which will be addressed in this article.
Collapse
Affiliation(s)
- Wolfgang A. Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Lindenberger Weg 19, Berlin 13125, Germany
| | - Valentin S. Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic of Internal Medicine III, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
| |
Collapse
|
6
|
Alba MA, Kermani TA, Unizony S, Murgia G, Prieto-González S, Salvarani C, Matteson EL. Relapses in giant cell arteritis: Updated review for clinical practice. Autoimmun Rev 2024; 23:103580. [PMID: 39048072 DOI: 10.1016/j.autrev.2024.103580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 07/20/2024] [Accepted: 07/20/2024] [Indexed: 07/27/2024]
Abstract
Giant cell arteritis (GCA), the most common primary vasculitis in adults, is a granulomatous systemic vasculitis usually affecting the aorta and its major branches, particularly the carotid and vertebral arteries. Although remission can be achieved in most patients with GCA using high-dose glucocorticoids (GC), relapses are frequent, occurring in >40% of GC-only treated patients, mostly during the first two years after diagnosis. Relapsing courses lead to high GC exposure, increasing the risk of treatment-related adverse effects. Although tocilizumab is an efficacious GC-sparing therapy that allows increased sustained remission and reduced cumulative GC doses, relapses are common after drug discontinuation. This narrative review examines the most relevant features of relapses in GCA, including its definition, classification, frequency, clinical, laboratory, and imaging characteristics, chronology, probable pathophysiology, and predictive factors. In addition, we discuss treatment options for relapsing patients and the effect of relapses on patient outcomes.
Collapse
Affiliation(s)
- Marco A Alba
- Systemic Autoimmune Diseases Unit, Department of Internal Medicine, Hospital Universitari Mútua Terrassa, Terrassa, Spain.
| | - Tanaz A Kermani
- Division of Rheumatology, University of California Los Angeles, Los Angeles, CA, USA
| | - Sebastian Unizony
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Giuseppe Murgia
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Sergio Prieto-González
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi Sunyer (IDIBAPS), Barcelona, Spain
| | - Carlo Salvarani
- Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Università di Modena e Reggio Emilia, Reggio Emilia, Italy
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| |
Collapse
|
7
|
Sugihara T, Yoshifuji H, Uchida HA, Maejima Y, Watanabe Y, Tanemoto K, Umezawa N, Manabe Y, Ishizaki J, Shirai T, Nagafuchi H, Hasegawa H, Niiro H, Ishii T, Nakaoka Y, Harigai M. Establishing clinical remission criteria for giant cell arteritis: Results of a Delphi exercise carried out by an expert panel of the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis. Mod Rheumatol 2024; 34:568-575. [PMID: 37225423 DOI: 10.1093/mr/road046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/06/2023] [Accepted: 05/09/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVE To develop a proposal for giant cell arteritis remission criteria in order to implement a treat-to-target algorithm. METHODS A task force consisting of 10 rheumatologists, 3 cardiologists, 1 nephrologist, and 1 cardiac surgeon was established in the Large-vessel Vasculitis Group of the Japanese Research Committee of the Ministry of Health, Labour and Welfare for Intractable Vasculitis to conduct a Delphi survey of remission criteria for giant cell arteritis. The survey was circulated among the members over four reiterations with four face-to-face meetings. Items with a mean score of ≥4 were extracted as items for defining remission criteria. RESULTS An initial literature review yielded a total of 117 candidate items for disease activity domains and treatment/comorbidity domains of remission criteria, of which 35 were extracted as disease activity domains (systematic symptoms, signs and symptoms of cranial and large-vessel area, inflammatory markers, and imaging findings). For the treatment/comorbidity domain, ≤5 mg/day of prednisolone 1 year after starting glucocorticoids was extracted. The definition of achievement of remission was the disappearance of active disease in the disease activity domain, normalization of inflammatory markers, and ≤5 mg/day of prednisolone. CONCLUSION We developed proposals for remission criteria to guide the implementation of a treat-to-target algorithm for giant cell arteritis.
Collapse
Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Division of Rheumatology and Allergy, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Faculty of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshiko Watanabe
- First Department of Physiology, Kawasaki Medical School, Kurashiki, Japan
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School, Kurashiki, Japan
| | - Natsuka Umezawa
- Department of Rheumatology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yusuke Manabe
- Department of Respiratory Medicine and Clinical Immunology, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
| | - Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Tsuyoshi Shirai
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroko Nagafuchi
- Division of Rheumatology and Allergy, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hitoshi Hasegawa
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Hiroaki Niiro
- Department of Medical Education, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Tomonori Ishii
- Clinical Research, Innovation and Education Center, Tohoku University Hospital, Sendai, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayoshi Harigai
- Division of Rheumatology, Department of Internal Medicine, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| |
Collapse
|
8
|
Grazzini S, Conticini E, Falsetti P, D’Alessandro M, Sota J, Terribili R, Baldi C, Fabiani C, Bargagli E, Cantarini L, Frediani B. Tocilizumab Vs Methotrexate in a Cohort of Patients Affected by Active GCA: A Comparative Clinical and Ultrasonographic Study. Biologics 2023; 17:151-160. [PMID: 38059132 PMCID: PMC10697083 DOI: 10.2147/btt.s431818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/31/2023] [Indexed: 12/08/2023]
Abstract
Introduction No head-to-head study has assessed the superiority of tocilizumab versus methotrexate in giant cell arteritis (GCA), and few studies have demonstrated its effectiveness in terms of ultrasonographic findings, but without a control group. The primary endpoint was to assess whether tocilizumab was superior to methotrexate in inducing normalization of US findings, whereas the secondary endpoint was to assess the effectiveness of precocious withdrawal of glucocorticoids. Methods We prospectively enrolled all the patients with active GCA at our clinic. The inclusion criteria were clinical diagnosis of GCA; active disease; and clinical, laboratory, and US data, evaluated using the halo count (HC) and OMERACT GCA Ultrasonography Score (OGUS). Evaluations were repeated at 3, 6, and 12 months. Results Twenty patients were treated with Tocilizumab and 9 with Methotrexate. All but three tocilizumab-treated patients achieved remission at six months, whereas at 12 months, all patients were in glucocorticoid-free remission. Up to three of the nine methotrexate patients experienced a lack of efficacy or minor relapses. Tocilizumab-treated patients showed a statistically significant difference between baseline and all follow-ups in terms of OGUS and HC, whereas the difference in the Methotrexate group was significant after 1 year. The mean glucocorticoid dosage significantly decreased in both groups. No severe adverse events or major relapses were reported. Conclusion Our study demonstrates the superiority in terms of rapidity of a tocilizumab-based scheme over a methotrexate-based scheme in inducing clinical and US remission. Precocious withdrawal of glucocorticoids did not increase the risk of relapse.
Collapse
Affiliation(s)
- Silvia Grazzini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Paolo Falsetti
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Miriana D’Alessandro
- Respiratory Diseases and Lung Transplant Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Jurgen Sota
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Riccardo Terribili
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Caterina Baldi
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
| | - Elena Bargagli
- Respiratory Diseases and Lung Transplant Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, Siena, Italy
| |
Collapse
|
9
|
Sugihara T, Uchida HA, Yoshifuji H, Maejima Y, Naniwa T, Katsumata Y, Okazaki T, Ishizaki J, Murakawa Y, Ogawa N, Dobashi H, Horita T, Tanaka Y, Furuta S, Takeuchi T, Komagata Y, Nakaoka Y, Harigai M. Association between the patterns of large-vessel lesions and treatment outcomes in patients with large-vessel giant cell arteritis. Mod Rheumatol 2023; 33:1145-1153. [PMID: 36218378 DOI: 10.1093/mr/roac122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES We aimed to identify associations between patterns of large-vessel lesions of large-vessel giant cell arteritis (LV-GCA) and treatment outcomes. METHODS We extracted data on 68 newly diagnosed patients with LV-GCA from a retrospective, multi-centric, nationwide registry of GCA patients treated with glucocorticoids between 2007 and 2014. Patients with aortic lesions were identified based on the findings from contrast-enhanced computed tomography, magnetic resonance imaging, or positron emission tomography-computed tomography (Group 2, n = 49). Patients without aortic lesions were subdivided into LV-GCA with or without subclavian lesions defined as Group 1 (n = 9) or Group 3 (n = 10), respectively. The primary outcome evaluation was failure to achieve clinical remission by Week 24 and/or relapse within 104 weeks. RESULTS The mean age and proportion of patients with cranial lesions and polymyalgia rheumatica in Group 2 were numerically lower than in the other two groups. Large-vessel lesions in Group 3 included carotid, pulmonary, renal, hepatic, or mesenteric lesions. The cumulative rate of poor treatment outcomes >2 years was 11.1%, 55.3%, and 88.0% in Groups 1, 2, and 3, respectively (by Kaplan-Meier analysis). The mean time to poor outcome was significantly different between the groups. CONCLUSIONS Classification by subclavian and aortic lesions may be useful to determine treatment strategy.
Collapse
Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
- Department of Internal Medicine, Division of Rheumatologyand Allergology, St. Marianna University Faculty of Medicine, Kawasaki, Japan
| | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taio Naniwa
- Department of Internal Medicine, Division of Rheumatology, Nagoya City University Hospital, Nagoya, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuhiro Katsumata
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takahiro Okazaki
- Department of Internal Medicine, Division of Rheumatologyand Allergology, St. Marianna University Faculty of Medicine, Kawasaki, Japan
- National Hospital Organization, Shizuoka Medical Center, Shimizu, Japan
| | - Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Noriyoshi Ogawa
- Department of Internal Medicine 3, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tetsuya Horita
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Tsutomu Takeuchi
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Komagata
- First Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayoshi Harigai
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| |
Collapse
|
10
|
Samec MJ, Rakholiya J, Langenfeld H, Crowson CS, Abril A, Wang B, Mertz L, Rodriguez-Pla A, Bansal P, Burke M, Jaquith J, Weyand C, Warrington KJ, Koster MJ. Relapse Risk and Safety of Long-Term Tocilizumab Use Among Patients With Giant Cell Arteritis: A Single-Enterprise Cohort Study. J Rheumatol 2023; 50:1310-1317. [PMID: 37321636 PMCID: PMC10543396 DOI: 10.3899/jrheum.2022-1214] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2023] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of tocilizumab (TCZ) in giant cell arteritis (GCA) in a large North American cohort. METHODS Patients with GCA treated with TCZ between January 1, 2010, and May 15, 2020, were retrospectively identified. Kaplan-Meier methods were used to estimate time to TCZ discontinuation and time to first relapse after TCZ discontinuation. Poisson regression models were used to compare annualized relapse rates before, during, and after TCZ use. Age- and sex-adjusted risk factors associated with relapse on and off TCZ and development of adverse events of significant interest (AESIs) were examined using Cox models. RESULTS One hundred fourteen patients (60.5% female) were included with mean (SD) age 70.4 (8.2) years. Median duration from GCA diagnosis to TCZ start was 4.5 months. Median overall duration of TCZ treatment was 2.3 years. Relapse rate prior to TCZ start (0.84 relapses/person-year) was 3-fold reduced while on TCZ (0.28 relapses/person-year; P < 0.001) but increased to 0.64 relapses/person-year after TCZ discontinuation. Fifty-two patients stopped TCZ after a median of 16.8 months; 27 relapsed after discontinuation (median: 8.4 months; 58% relapsed within 12 months). Only 14.9% of patients stopped TCZ because of AESIs. Neither dose/route of TCZ, presence of large-vessel vasculitis, nor duration of TCZ therapy prior to discontinuation predicted relapse after TCZ stop. CONCLUSION TCZ is well tolerated in GCA, with low rates of discontinuation for AESIs. However, relapse occurred in > 50% despite median treatment > 12 months. Since the duration of TCZ prior to discontinuation did not significantly affect subsequent risk of GCA recurrence, further research is needed to determine the optimal duration of therapy.
Collapse
Affiliation(s)
- Matthew J Samec
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Jigisha Rakholiya
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Hannah Langenfeld
- H. Langenfeld, MPH, Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Cynthia S Crowson
- C.S. Crowson, PhD, Division of Rheumatology, and Division of Clinical Trials and Biostatistics, Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Andy Abril
- A. Abril, MD, B. Wang, MD, Division of Rheumatology, Mayo Clinic, Jacksonville, Florida
| | - Benjamin Wang
- A. Abril, MD, B. Wang, MD, Division of Rheumatology, Mayo Clinic, Jacksonville, Florida
| | - Lester Mertz
- L. Mertz, MD, A. Rodriguez-Pla, MD, PhD, Division of Rheumatology, Mayo Clinic, Scottsdale, Arizona
| | - Alicia Rodriguez-Pla
- L. Mertz, MD, A. Rodriguez-Pla, MD, PhD, Division of Rheumatology, Mayo Clinic, Scottsdale, Arizona
| | - Pankaj Bansal
- P. Bansal, MBBS, Division of Rheumatology, Mayo Clinic Health System, Eau Claire, Wisconsin, USA
| | - Michelle Burke
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Jane Jaquith
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Cornelia Weyand
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth J Warrington
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota
| | - Matthew J Koster
- M.J. Samec, MD, J. Rakholiya, MBBS, M. Burke, APRN, CNP, J. Jaquith, CCRC, C. Weyand, MD, PhD, K.J. Warrington, MD, M.J. Koster, MD, Division of Rheumatology, Mayo Clinic, Rochester, Minnesota;
| |
Collapse
|
11
|
Casteleyn V, Schmidt WA. [Imaging of large vessel vasculitis]. Z Rheumatol 2023; 82:646-653. [PMID: 37620546 DOI: 10.1007/s00393-023-01405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2023] [Indexed: 08/26/2023]
Abstract
Giant cell arteritis (GCA) and Takayasu arteritis (TAK) are the most important primary large vessel vasculitides. A rapid and reliable confirmation of the diagnosis is necessary to prevent ischemic complications. Patients with extracranial GCA and TAK often present with unspecific symptoms. Since 2018 the EULAR has recommended imaging as an alternative to histology for confirming the diagnosis. Ultrasound is particularly recommended as the primary imaging modality for cranial GCA. Alternatively, MRI and PET can be used for the diagnostics of temporal arteritis. Ultrasound is also valuable for extracranial GCA, alternatively MRI, CT or PET-CT can be used. This review discusses the current status of imaging techniques in large vessel vasculitis as well as the advantages and disadvantages. The focus is on ultrasound, which is increasingly being used as the primary diagnostic modality due to its excellent diagnostic quality, wide availability, noninvasiveness, and patient friendliness. Technical aspects, prerequisites, and normal and pathological findings are also presented. Finally, an outlook is given on promising new developments, such as scores for evaluating disease progression and contrast-enhanced ultrasound.
Collapse
Affiliation(s)
- Vincent Casteleyn
- Medizinische Klinik mit Schwerpunkt Rheumatologie und klinische Immunologie, Charité Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, 10117, Berlin, Deutschland.
| | - Wolfgang Andreas Schmidt
- Abteilung Rheumatologie und Klinische Immunologie, Immanuel Krankenhaus Berlin, Standort Berlin-Buch, Lindenberger Weg 19, 13125, Berlin, Deutschland
| |
Collapse
|
12
|
Nielsen BD, Therkildsen P, Keller KK, Gormsen LC, Hansen IT, Hauge EM. Ultrasonography in the assessment of disease activity in cranial and large-vessel giant cell arteritis: a prospective follow-up study. Rheumatology (Oxford) 2023; 62:3084-3094. [PMID: 36651670 DOI: 10.1093/rheumatology/kead028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES We evaluated sensitivity to change and discriminative abilities of vascular US scores in disease monitoring in the follow-up of a prospective cohort of new-onset cranial and large-vessel (LV) GCA patients. METHODS Baseline and follow-up (8 weeks, 24 weeks and 15 months) US of temporal arteries (TA), carotid and axillary arteries (LV) included assessment of halo and measurement of the intima media complex (IMC). Max IMC, max halo IMC, sum IMC, sum halo IMC, mean IMC, halo count and the Southend halo score were calculated. The provisional OMERACT US score, OGUS, was obtained, taking the average of temporal arteries and axillary arteries IMCs divided by their normal cut-off values. RESULTS Baseline US was positive in 44/47 patients (72% TA, 72% LV). Sensitivity to change of all composite US scores containing TAs was evident by week 8 onward. LVs responded poorly and new axillary US lesions emerged in six patients despite clinical remission. The OGUS showed a large magnitude of change and is considered the score least prone to potential bias. All TA-based US scores showed moderate-strong correlation with disease activity markers. OGUS, TA halo count, Southend TA halo score, TA sum IMC and TA mean IMC showed potential to discriminate remission and relapse with area under the curve ≥0.8. CONCLUSIONS The OGUS is suggested as an outcome measurement for the assessment of treatment response in clinical trials. The abilities of US scores to discriminate remission and relapse are encouraging and should be further explored.
Collapse
Affiliation(s)
- Berit Dalsgaard Nielsen
- Department of Medicine, The Regional Hospital in Horsens, Horsens, Denmark
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Philip Therkildsen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kresten K Keller
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lars C Gormsen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Nuclear Medicine and PET Centre, Aarhus University Hospital, Aarhus, Denmark
| | - Ib T Hansen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
13
|
Bosch P, Bond M, Dejaco C, Ponte C, Mackie SL, Falzon L, Schmidt WA, Ramiro S. Imaging in diagnosis, monitoring and outcome prediction of large vessel vasculitis: a systematic literature review and meta-analysis informing the 2023 update of the EULAR recommendations. RMD Open 2023; 9:e003379. [PMID: 37620113 PMCID: PMC10450079 DOI: 10.1136/rmdopen-2023-003379] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/07/2023] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES To update the evidence on imaging for diagnosis, monitoring and outcome prediction in large vessel vasculitis (LVV) to inform the 2023 update of the European Alliance of Associations for Rheumatology recommendations on imaging in LVV. METHODS Systematic literature review (SLR) (2017-2022) including prospective cohort and cross-sectional studies (>20 participants) on diagnostic, monitoring, outcome prediction and technical aspects of LVV imaging. Diagnostic accuracy data were meta-analysed in combination with data from an earlier (2017) SLR. RESULTS The update retrieved 38 studies, giving a total of 81 studies when combined with the 2017 SLR. For giant cell arteritis (GCA), and taking clinical diagnosis as a reference standard, low risk of bias (RoB) studies yielded pooled sensitivities and specificities (95% CI) of 88% (82% to 92%) and 96% (95% CI 86% to 99%) for ultrasound (n=8 studies), 81% (95% CI 71% to 89%) and 98% (95% CI 89% to 100%) for MRI (n=3) and 76% (95% CI 67% to 83%) and 95% (95% CI 71% to 99%) for fluorodeoxyglucose positron emission tomography (FDG-PET, n=4), respectively. Compared with studies assessing cranial arteries only, low RoB studies with ultrasound assessing both cranial and extracranial arteries revealed a higher sensitivity (93% (95% CI 88% to 96%) vs 80% (95% CI 71% to 87%)) with comparable specificity (94% (95% CI 83% to 98%) vs 97% (95% CI 71% to 100%)). No new studies on diagnostic imaging for Takayasu arteritis (TAK) were found. Some monitoring studies in GCA or TAK reported associations of imaging with clinical signs of inflammation. No evidence was found to determine whether imaging severity might predict worse clinical outcomes. CONCLUSION Ultrasound, MRI and FDG-PET revealed a good performance for the diagnosis of GCA. Cranial and extracranial vascular ultrasound had a higher pooled sensitivity with similar specificity compared with limited cranial ultrasound.
Collapse
Affiliation(s)
- Philipp Bosch
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Brunico, Italy
| | - Christian Dejaco
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsius Medical University, Brunico, Italy
| | - Cristina Ponte
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Rheumatology Department, Hospital de Santa Maria, Centro Hospitalar de Lisboa Norte, EPE, Lisbon, Portugal
| | - Sarah Louise Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Louise Falzon
- Health Economics and Decision Science, The University of Sheffield, Sheffield, UK
| | - Wolfgang A Schmidt
- Department of Rheumatology, Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| |
Collapse
|
14
|
Tomelleri A, van der Geest KSM, Khurshid MA, Sebastian A, Coath F, Robbins D, Pierscionek B, Dejaco C, Matteson E, van Sleen Y, Dasgupta B. Disease stratification in GCA and PMR: state of the art and future perspectives. Nat Rev Rheumatol 2023:10.1038/s41584-023-00976-8. [PMID: 37308659 DOI: 10.1038/s41584-023-00976-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/14/2023]
Abstract
Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are closely related conditions characterized by systemic inflammation, a predominant IL-6 signature, an excellent response to glucocorticoids, a tendency to a chronic and relapsing course, and older age of the affected population. This Review highlights the emerging view that these diseases should be approached as linked conditions, unified under the term GCA-PMR spectrum disease (GPSD). In addition, GCA and PMR should be seen as non-monolithic conditions, with different risks of developing acute ischaemic complications and chronic vascular and tissue damage, different responses to available therapies and disparate relapse rates. A comprehensive stratification strategy for GPSD, guided by clinical findings, imaging and laboratory data, facilitates appropriate therapy and cost-effective use of health-economic resources. Patients presenting with predominant cranial symptoms and vascular involvement, who usually have a borderline elevation of inflammatory markers, are at an increased risk of sight loss in early disease but have fewer relapses in the long term, whereas the opposite is observed in patients with predominant large-vessel vasculitis. How the involvement of peripheral joint structures affects disease outcomes remains uncertain and understudied. In the future, all cases of new-onset GPSD should undergo early disease stratification, with their management adapted accordingly.
Collapse
Affiliation(s)
- Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Alwin Sebastian
- Department of Rheumatology, University Hospital Limerick, Limerick, Ireland
| | - Fiona Coath
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK
| | - Daniel Robbins
- Medical Technology Research Centre, School of Allied Health, Anglia Ruskin University, Chelmsford, UK
| | - Barbara Pierscionek
- Faculty of Health Education Medicine and Social Care, Medical Technology Research Centre, Anglia Ruskin University, Chelmsford Campus, Chelmsford, UK
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck (ASAA-SABES), Teaching Hospital of the Paracelsus Medical University, Bruneck, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria
| | - Eric Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-sea, UK.
| |
Collapse
|
15
|
Sanchez-Alvarez C, Bond M, Soowamber M, Camellino D, Anderson M, Langford CA, Dejaco C, Touma Z, Ramiro S. Measuring treatment outcomes and change in disease activity in giant cell arteritis: a systematic literature review informing the development of the EULAR-ACR response criteria on behalf of the EULAR-ACR response criteria in giant cell arteritis task force. RMD Open 2023; 9:e003233. [PMID: 37349123 PMCID: PMC10314653 DOI: 10.1136/rmdopen-2023-003233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 05/12/2023] [Indexed: 06/24/2023] Open
Abstract
OBJECTIVES To identify criteria and descriptors used to measure response to treatment and change in disease activity in giant cell arteritis (GCA). METHODS A systematic literature review (SLR) to retrieve randomised controlled trials (RCTs) and longitudinal observational studies (LOS). Criteria and descriptors of active disease, remission, response, improvement, worsening and relapse were extracted. RCTs, LOS with >20 subjects, and qualitative research studies were included. RESULTS 10 593 studies were retrieved, of which 116 were included (11 RCTs, 104 LOS, 1 qualitative study). No unified definition of response to therapy was found. Most RCTs used composite endpoints to assess treatment outcomes. Active disease was described in all RCTs and 19% of LOS; and was largely defined by a combination of clinical and laboratory components. Remission was reported in 73% of RCTs and 42% of LOS; It was predominantly defined as the combination of clinical and laboratory components. One LOS reported response with a definition resembling the definition of remission from other studies. Improvement was rarely used as an endpoint and it was mostly a surrogate of remission. No study specifically defined worsening. Relapse was reported in all RCTs and 86% of LOS. It was predominantly defined as the combination of clinical, laboratory and treatment components. CONCLUSIONS The results of this SLR demonstrate that definitions of response used in clinical studies of GCA are scant and heterogeneous. RCTs and LOS mainly used remission and relapse as treatment outcomes. The descriptors identified will inform the development of the future European Alliance of Associations for Rheumatology-American College of Rheumatology response criteria for GCA.
Collapse
Affiliation(s)
- Catalina Sanchez-Alvarez
- Division of Rheumatology & Clinical Immunology, Department of Internal Medicine, University of Florida, Gainesville, Florida, USA
| | - Milena Bond
- Department of Rheumatology, Hospital of Bruneck, (ASAA-SABES), Teaching hospital of the Paracelsus University, Bruneck, Italy
| | - Medha Soowamber
- Department of Rheumatology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Dario Camellino
- Department of Rheumatology, Local Health Trust, Genoa, Italy
| | - Melanie Anderson
- Department of Library and Information Services, University Health Network, Toronto, Ontario, Canada
| | - Carol A Langford
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, Ohio, USA
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Bruneck, (ASAA-SABES), Teaching hospital of the Paracelsus University, Bruneck, Italy
- Rheumatology, Medical University Graz, Graz, Austria
| | - Zahi Touma
- Department of Medicine, Division of Rheumatology, University of Toronto, Toronto, Ontario, Canada
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Zuyderland Medical Center, Heerlen, The Netherlands
| |
Collapse
|
16
|
Galli E, Pipitone N, Salvarani C. The role of PET/CT in disease activity assessment in patients with large vessel vasculitis. Curr Opin Rheumatol 2023; 35:194-200. [PMID: 36866659 DOI: 10.1097/bor.0000000000000931] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
PURPOSE OF REVIEW The aim of this article was to review the recent contributions on the role of PET in assessing disease activity in patients with large-vessel vasculitis (giant cell arteritis and Takayasu arteritis). RECENT FINDINGS 18 FDG (fluorodeoxyglucose) vascular uptake in large-vessel vasculitis at PET shows moderate correlation with clinical indices, laboratory markers and signs of arterial involvement at morphological imaging. Limited data may suggest that 18 FDG (fluorodeoxyglucose) vascular uptake could predict relapses and (in Takayasu arteritis) the development of new angiographic vascular lesions. PET appears to be in general sensitive to change after treatment. SUMMARY While the role of PET in diagnosis large-vessel vasculitis is established, its role in evaluating disease activity is less clear-cut. PET may be used as an ancillary technique, but a comprehensive assessment, including clinical, laboratory and morphological imaging is still required to monitor patients with large-vessel vasculitis over time.
Collapse
Affiliation(s)
- Elena Galli
- Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia
| | | | - Carlo Salvarani
- Azienda USL-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia
| |
Collapse
|
17
|
Dejaco C, Ponte C, Monti S, Rozza D, Scirè CA, Terslev L, Bruyn GAW, Boumans D, Hartung W, Hočevar A, Milchert M, Døhn UM, Mukhtyar CB, Aschwanden M, Bosch P, Camellino D, Chrysidis S, Ciancio G, D'Agostino MA, Daikeler T, Dasgupta B, De Miguel E, Diamantopoulos AP, Duftner C, Agueda A, Fredberg U, Hanova P, Hansen IT, Hauge EM, Iagnocco A, Inanc N, Juche A, Karalilova R, Kawamoto T, Keller KK, Keen HI, Kermani TA, Kohler MJ, Koster M, Luqmani RA, Macchioni P, Mackie SL, Naredo E, Nielsen BD, Ogasawara M, Pineda C, Schäfer VS, Seitz L, Tomelleri A, Torralba KD, van der Geest KSM, Warrington KJ, Schmidt WA. The provisional OMERACT ultrasonography score for giant cell arteritis. Ann Rheum Dis 2023; 82:556-564. [PMID: 36600183 DOI: 10.1136/ard-2022-223367] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/26/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To develop an Outcome Measures in Rheumatology (OMERACT) ultrasonography score for monitoring disease activity in giant cell arteritis (GCA) and evaluate its metric properties. METHODS The OMERACT Instrument Selection Algorithm was followed. Forty-nine members of the OMERACT ultrasonography large vessel vasculitis working group were invited to seven Delphi rounds. An online reliability exercise was conducted using images of bilateral common temporal arteries, parietal and frontal branches as well as axillary arteries from 16 patients with GCA and 7 controls. Sensitivity to change and convergent construct validity were tested using data from a prospective cohort of patients with new GCA in which ultrasound-based intima-media thickness (IMT) measurements were conducted at weeks 1, 3, 6, 12 and 24. RESULTS Agreement was obtained (92.7%) for the OMERACT GCA Ultrasonography Score (OGUS), calculated as follows: sum of IMT measured in every segment divided by the rounded cut-off values of IMTs in each segment. The resulting value is then divided by the number of segments available. Thirty-five members conducted the reliability exercise, the interrater intraclass correlation coefficient (ICC) for the OGUS was 0.72-0.84 and the median intrareader ICC was 0.91. The prospective cohort consisted of 52 patients. Sensitivity to change between baseline and each follow-up visit up to week 24 yielded standardised mean differences from -1.19 to -2.16, corresponding to large and very large magnitudes of change, respectively. OGUS correlated moderately with erythrocyte sedimentation rate, C reactive protein and Birmingham Vasculitis Activity Score (corrcoeff 0.37-0.48). CONCLUSION We developed a provisional OGUS for potential use in clinical trials.
Collapse
Affiliation(s)
- Christian Dejaco
- Department of Rheumatology, Medical University of Graz, Graz, Steiermark, Austria
- Department of Rheumatology, Brunico Hospital, Brunico, Trentino-Alto Adige, Italy
| | - Cristina Ponte
- Department of Rheumatology, Centro Hospitalar Universitário Lisboa Norte, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
| | - Sara Monti
- Department of Internal Medicine and Therapeutics, Università di Pavia, Pavia, Italy
- Division of Rheumatology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | | | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
- Clinical Medicine, Copenhagen University, Copenhagen, Denmark
| | | | - Dennis Boumans
- Rheumatology and Clinical Immunology, Hospital Group Twente, Almelo, The Netherlands
| | | | - Alojzija Hočevar
- Department of Rheumatology, Universitiy Medical Centre Ljubljana, Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Marcin Milchert
- Department of Rheumatology, Internal Medicine, Geriatrics and Clinical Immunology, Pomeranian Medical University in Szczecin, Szczecin, Poland
| | - Uffe Møller Døhn
- Copenhagen Center for Arthritis Research (COPECARE), Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark
| | - Chetan B Mukhtyar
- Vasculitis Service, Rheumatology Department, Norfolk and Norwich University Hospital NHS Trust, Norwich, UK
| | | | - Philipp Bosch
- Department of Rheumatology, Medical University of Graz, Graz, Steiermark, Austria
| | - Dario Camellino
- Division of Rheumatology, Department of Medical Specialties, Azienda Sanitaria Locale 3 Genovese, Arenzano, Genoa, Italy
| | | | - Giovanni Ciancio
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | | | - Thomas Daikeler
- Clinic for Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Bhaskar Dasgupta
- Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff-on-Sea, UK
| | | | - Andreas P Diamantopoulos
- Section of Rheumatology, Division of Internal Medicine, Akershus University Hospital, Lorenskog, Norway
| | - Christina Duftner
- Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria
| | - Ana Agueda
- Centro Hospitalar do Baixo Vouga E.P.E, Aveiro, Portugal
| | - Ulrich Fredberg
- Diagnostic Centre, Silkeborg Regional Hospital, Silkeborg, Denmark
- Rheumatology, Odense University Hospital, Odense, Denmark
| | - Petra Hanova
- Rheumatology, Institute of Rheumatology, Prague, Czech Republic
- Rheumatology, Hána CB spol. s r.o, Ceske Budejovice, Czech Republic
| | - Ib Tønder Hansen
- Department of Rheumatology, Aarhus Copenhagen Hospital, Aarhus, Denmark
| | - Ellen-Margrethe Hauge
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Annamaria Iagnocco
- Academic Rheumatology Center, Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Turin, Italy
| | - Nevsun Inanc
- Rheumatology, Marmara University School of Medicine, Istanbul, Turkey
| | - Aaron Juche
- Department of Rheumatology, Immanuel Hospital, Berlin, Germany
| | | | - Toshio Kawamoto
- Immunology, Juntendo University School of Medicine, Tokyo, Japan
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Kresten Krarup Keller
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Tanaz A Kermani
- Rheumatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Minna J Kohler
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew Koster
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedicx, Rheumatology and Musculoskeletal Science (NDORMs), University of Oxford, Oxford, UK
| | | | | | - Esperanza Naredo
- Department of Rheumatology and Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, Madrid, Spain
| | - Berit Dalsgaard Nielsen
- Department of Rheumatology, Aarhus University Hospital, Aarhus, Denmark
- Department of Medicine, Regional Hospital Horsens, Horsens, Denmark
| | - Michihiro Ogasawara
- Department of Internal Medicine and Rheumatology, Juntendo University School of Medicine, Tokyo, Japan
| | - Carlos Pineda
- Division of Rheumatology, Instituto Nacional de Rehabilitacion Luis Guillermo Ibarra Ibarra, Mexico City, Mexico
| | | | - Luca Seitz
- Rheumatology and Immunology, Inselspital University Hospital Bern, Bern, Switzerland
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Karina D Torralba
- Division of Rheumatology, Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Kornelis S M van der Geest
- Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Kenneth J Warrington
- Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Wolfgang A Schmidt
- Rheumatology, Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
| |
Collapse
|
18
|
Springer JM, Kermani TA. Recent advances in the treatment of giant cell arteritis. Best Pract Res Clin Rheumatol 2023; 37:101830. [PMID: 37328409 DOI: 10.1016/j.berh.2023.101830] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/20/2023] [Accepted: 04/23/2023] [Indexed: 06/18/2023]
Abstract
Giant cell arteritis (GCA) is a systemic, granulomatous, large-vessel vasculitis that affects individuals over the age of 50 years. Morbidity from disease includes cranial manifestations which can cause irreversible blindness, while extra-cranial manifestations can cause vascular damage with large-artery stenosis, occlusions, aortitis, aneurysms, and dissections. Glucocorticoids while efficacious are associated with significant adverse effects. Furthermore, despite treatment with glucocorticoids, relapses are common. An understanding of the pathogenesis of GCA has led to the discovery of tocilizumab as an efficacious steroid-sparing therapy while additional therapeutic targets affecting different inflammatory pathways are under investigation. Surgical treatment may be indicated in cases of refractory ischemia or aortic complications but data on surgical outcomes are limited. Despite the recent advances, many unmet needs exist, including the identification of patients or subsets of GCA who would benefit from earlier initiation of adjunctive therapies, patients who may warrant long-term immunosuppression and medications that sustain permanent remission. The impact of medications like tocilizumab on long-term outcomes, including the development of aortic aneurysms and vascular damage also warrants investigation.
Collapse
Affiliation(s)
- Jason M Springer
- Vanderbilt University Medical Center, 1161 21st Avenue Sound, T3113 Medical Center North, Nashville, TN, 37232, USA.
| | - Tanaz A Kermani
- University of California Los Angeles, 2020 Santa Monica Boulevard, Suite 540, Santa Monica, CA, 90404, USA.
| |
Collapse
|
19
|
Conticini E, Falsetti P, Fabiani C, Baldi C, Grazzini S, Tosi GM, Cantarini L, Frediani B. Color Doppler Eye Ultrasonography in giant cell arteritis: differential diagnosis between arteritic and non-arteritic sudden blindness. J Ultrasound 2023; 26:313-320. [PMID: 36550390 PMCID: PMC10063765 DOI: 10.1007/s40477-022-00757-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/20/2022] [Indexed: 12/24/2022] Open
Abstract
PURPOSE Temporal (TA) and axillary (AXA) arteries Color Doppler Ultrasonography (CDUS) is the most reliable diagnostic technique for the diagnosis of giant cell arteritis (GCA), displaying high sensitivity and specificity. Nevertheless, CDUS is still poorly performed in the common clinical practice, being employed only by rheumatologists with a relevant expertise in this field. Color Doppler Eye Ultrasound (CDEUS) is a procedure variously employed in ophthalmology and preliminary findings have displayed a possible role also in the diagnostic work-up of GCA. Aim of this study was to assess whether CDEUS may play a role in the differential diagnosis between arteritic and non-arteritic blindness. METHODS We prospectively included all patients evaluated since September 2021 to May 2022 by our Ophthalmology Unit for sudden blindness and referred to our Vasculitis Clinic in the suspicion of GCA. All patients underwent complete ophthalmological evaluation, routine blood tests, AxA and TA CDUS and CDEUS. According to the definite diagnosis, patients were divided in the following subgroups: (A) patients suffering from arteritic central retinal artery occlusion (CRAO), (B) patients suffering from non-arteritic CRAO, (C) patients suffering from arteritic anterior ischemic optic neuropathy (AION), (D) patients suffering from non-arteritic AION. RESULTS During the observational period, we included a total of 25 patients suffering from sudden blindness and referred to Vasculitis Clinic for ruling out GCA. Patients belonging to group A showed no flow or reduced flow within the territory of central retinal artery (CRA), no "spot sign" and positive TA CDUS; on the other hand, patients from group B presented normal TA CDUS, no flow or reduced flow within the territory of CRA and the presence of "spot sign". Conversely, no relevant difference was evidenced at CDEUS in patients with and without arteritic AION. CONCLUSION Our preliminary data displayed a good reliability of CDEUS in distinguishing between arteritic and non-arteritic CRAO, while no difference was assessed between arteritic and non-arteritic AION. Since AION represents the most common presentation of cranial GCA, CDEUS does not seem a reliable procedure in the diagnostic work-up of GCA and should be restricted only to the exclusion of thrombo-embolic occlusions within the territory of central retinal artery.
Collapse
Affiliation(s)
- Edoardo Conticini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Paolo Falsetti
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Claudia Fabiani
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, University of Siena, Siena, Italy
| | - Caterina Baldi
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Silvia Grazzini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| | - Gian Marco Tosi
- Department of Medicine, Surgery and Neurosciences, Ophthalmology Unit, University of Siena, Siena, Italy
| | - Luca Cantarini
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy.
| | - Bruno Frediani
- Department of Medicine, Surgery and Neurosciences, Rheumatology Unit, University of Siena, Viale Mario Bracci, 16, 53100, Siena, Italy
| |
Collapse
|
20
|
Schmidt WA. Vascular ultrasound in rheumatology practice. Best Pract Res Clin Rheumatol 2023; 37:101847. [PMID: 37419758 DOI: 10.1016/j.berh.2023.101847] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/09/2023]
Abstract
Rheumatologists are increasingly using vascular ultrasound. Several guidelines now recommend ultrasound as the first diagnostic modality in giant cell arteritis (GCA). The German curriculum for rheumatology training has recently included ultrasound for the acute diagnosis of vasculitis. Recent studies have shown that ultrasound of temporal, axillary, subclavian, and vertebral arteries has sensitivities and specificities of >90%. Vascular ultrasound detects subclinical GCA in approximately 20% of patients with "pure" polymyalgia rheumatica. GCA fast-track clinics might regularly include these patients. A new score based on the intima-media thickness of the temporal and axillary arteries allows the monitoring of structural changes with treatment. The score decreases faster for the temporal arteries than it does for the axillary arteries. Measuring the diameter of the ascending aorta and the aortic arch might become a fast and cost-effective tool for the long-term monitoring of aortic aneurysms in extracranial GCA. Vascular ultrasound also has a role for Takayasu arteritis, thrombosis, Behçet's syndrome, and Raynaud's phenomenon.
Collapse
Affiliation(s)
- Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Center for Rheumatology Berlin-Buch, Lindenberger Weg 19, 13125 Berlin, Germany.
| |
Collapse
|
21
|
Jamar F, Gormsen LC, Yildiz H, Slart RH, van der Geest KS, Gheysens O. The role of PET/CT in large vessel vasculitis and related disorders: diagnosis, extent evaluation and assessment of therapy response. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2022; 66:182-193. [PMID: 36066110 DOI: 10.23736/s1824-4785.22.03465-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Large vessel vasculitides (LVV) are defined as chronic inflammatory disorders that affect the arteries with two major variants being distinguished: giant cell arteritis (GCA) and Takayasu's arteritis (TAK). These often present with nonspecific constitutional symptoms which makes an accurate diagnosis often challenging. Nevertheless, timely diagnosis is of utmost importance to initiate treatment and to avoid potential life-threatening complications. [18F]FDG-PET/CT is nowadays widely accepted as useful tool to aid in the diagnosis of large vessel vasculitis. However, its role to monitor disease activity and to predict disease relapse during follow-up is less obvious since vascular [18F]FDG uptake can be detected in the absence of clinical or biochemical signs of disease activity. In addition to the two major variants, [18F]FDG-PET/CT has shown promise in (peri-)aortitis and related disorders. This article aims to provide an update on the current knowledge and limitations of [18F]FDG-PET/CT for the diagnosis and assessment of treatment response in LVV. Furthermore, other radiopharmaceuticals targeting key components of the vascular immune system are being discussed which could provide an interesting alternative to image vascular inflammation in LVV.
Collapse
Affiliation(s)
- François Jamar
- Department of Nuclear Medicine, Saint-Luc University Clinics and Institute of Clinical and Experimental Research (IREC), Catholic University of Louvain (UCLouvain), Brussels, Belgium -
| | - Lars C Gormsen
- Department of Nuclear Medicine and PET Center, Aarhus University Hospital, Aarhus, Denmark
| | - Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Saint-Luc University Clinics, Brussels, Belgium
| | - Riemer H Slart
- Department of Nuclear Medicine and Molecular Imaging, University Medical Center of Groningen, University of Groningen, Groningen, the Netherlands
- Department of Biomedical Photonic Imaging, Faculty of Science and Technology, University of Twente, Enschede, the Netherlands
| | - Kornelis S van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Center of Groningen, University of Groningen, Groningen, the Netherlands
| | - Olivier Gheysens
- Department of Nuclear Medicine, Saint-Luc University Clinics and Institute of Clinical and Experimental Research (IREC), Catholic University of Louvain (UCLouvain), Brussels, Belgium
| |
Collapse
|
22
|
Cronin O, Preston H, Fahmy H, Kuske B, Singh M, Scott N, Kerrigan S, Moran L, Harvie J, Harris H, Hauser B, McKay ND. Tocilizumab for the treatment of giant cell arteritis in Scotland: a report on behalf of the Scottish Society for Rheumatology standards subgroup. Rheumatol Adv Pract 2022; 6:rkac017. [PMID: 35368971 PMCID: PMC8969593 DOI: 10.1093/rap/rkac017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/22/2022] [Indexed: 11/21/2022] Open
Abstract
Objectives The aim was to describe a modern National Health Service (NHS) Scotland cohort of patients with GCA over 12 months of care to include clinical presentation, practices relating to assessment and treatment, and specifically, the use of tocilizumab. Methods A multicentre audit of patients newly diagnosed with GCA between November 2019 and October 2021 was established on behalf of the Scottish Society for Rheumatology. Clinical data were collected retrospectively by rheumatology teams at participating NHS centres using electronic patient records. An extended cohort of patients from NHS Lothian was examined to investigate outcomes of tocilizumab use for >1 year. Results Sixty-three patients from three NHS Scotland health boards were included, with analysis of data from 216 clinic episodes. Mean follow-up was 371 days. Mean age was 71 years; 62% were female. The most common presenting features were headache (93.6%), scalp tenderness (82.5%) and ocular symptoms (24%). At baseline, 63% of patients had at least one existing risk factor for adverse outcomes from high-dose CS use, namely hypertension (57.1%), diabetes (24%) and osteoporosis (11%). Thirty per cent of all patients (19 of 63) received tocilizumab, with only 11% (7 of 63) receiving tocilizumab owing to glucocorticoid risk factors at baseline. One-quarter of all patients (16 of 63) experienced relapse of GCA during follow-up, of whom six were subsequently treated with tocilizumab. Conclusion This multicentre audit demonstrates that despite its availability for patients with risk factors for CS adversity and those who suffer relapse of GCA, tocilizumab is used in less than one-quarter of patients who might benefit. The reasons for this require further exploration.
Collapse
Affiliation(s)
- Owen Cronin
- Rheumatic Diseases Unit, Western General Hospital
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh
| | | | - Heba Fahmy
- Rheumatic Diseases Unit, Western General Hospital
| | | | | | - Naomi Scott
- Rheumatic Diseases Unit, Western General Hospital
| | - Sean Kerrigan
- Department of Rheumatology, Forth Valley Royal Hospital, Larbert
| | - Lucy Moran
- Department of Rheumatology, Dumfries and Galloway Royal Infirmary, Dumfries, UK
| | - John Harvie
- Department of Rheumatology, Forth Valley Royal Hospital, Larbert
| | - Helen Harris
- Rheumatic Diseases Unit, Western General Hospital
| | - Barbara Hauser
- Rheumatic Diseases Unit, Western General Hospital
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh
| | - Neil D McKay
- Rheumatic Diseases Unit, Western General Hospital
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh
| |
Collapse
|
23
|
Sandovici M, van der Geest N, van Sleen Y, Brouwer E. Need and value of targeted immunosuppressive therapy in giant cell arteritis. RMD Open 2022; 8:e001652. [PMID: 35149602 PMCID: PMC8845325 DOI: 10.1136/rmdopen-2021-001652] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/17/2022] [Indexed: 11/30/2022] Open
Abstract
Despite the heterogeneity of the giant cell arteritis (GCA) at the level of clinical manifestations and the cellular and molecular players involved in its pathogenesis, GCA is still treated with standardised regimens largely based on glucocorticoids (GC). Long-term use of high dosages of GC as required in GCA are associated with many clinically relevant side effects. In the recent years, the interleukin-6 receptor blocker tocilizumab has become available as the only registered targeted immunosuppressive agent in GCA. However, immunological heterogeneity may require different pathways to be targeted in order to achieve a clinical, immunological and vascular remission in GCA. The advances in the targeted blockade of various molecular pathways involved in other inflammatory and autoimmune diseases have catalyzed the research on targeted therapy in GCA. This article gives an overview of the studies with targeted immunosuppressive treatments in GCA, with a focus on their clinical value, including their effects at the level of vascular inflammation.
Collapse
Affiliation(s)
- Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - Niels van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - Yannick van Sleen
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, Groningen, Netherlands
| |
Collapse
|
24
|
Abstract
Large-vessel vasculitis (LVV) manifests as inflammation of the aorta and its major branches and is the most common primary vasculitis in adults. LVV comprises two distinct conditions, giant cell arteritis and Takayasu arteritis, although the phenotypic spectrum of primary LVV is complex. Non-specific symptoms often predominate and so patients with LVV present to a range of health-care providers and settings. Rapid diagnosis, specialist referral and early treatment are key to good patient outcomes. Unfortunately, disease relapse remains common and chronic vascular complications are a source of considerable morbidity. Although accurate monitoring of disease activity is challenging, progress in vascular imaging techniques and the measurement of laboratory biomarkers may facilitate better matching of treatment intensity with disease activity. Further, advances in our understanding of disease pathophysiology have paved the way for novel biologic treatments that target important mediators of disease in both giant cell arteritis and Takayasu arteritis. This work has highlighted the substantial heterogeneity present within LVV and the importance of an individualized therapeutic approach. Future work will focus on understanding the mechanisms of persisting vascular inflammation, which will inform the development of increasingly sophisticated imaging technologies. Together, these will enable better disease prognostication, limit treatment-associated adverse effects, and facilitate targeted development and use of novel therapies.
Collapse
|
25
|
Seitz L, Christ L, Lötscher F, Scholz G, Sarbu AC, Bütikofer L, Kollert F, Schmidt WA, Reichenbach S, Villiger PM. Quantitative ultrasound to monitor the vascular response to tocilizumab in giant cell arteritis. Rheumatology (Oxford) 2021; 60:5052-5059. [PMID: 34117737 PMCID: PMC8566271 DOI: 10.1093/rheumatology/keab484] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To characterize the effect of ultra-short glucocorticoids followed by Tocilizumab monotherapy on the intima-media thickness (IMT) in GCA. METHODS Eighteen GCA patients received 500 mg for 3 consecutive days (total of 1500mg) i.v. methylprednisolone on days 0-2, followed by i.v. Tocilizumab (8 mg/kg) on day 3 and thereafter weekly s.c. Tocilizumab injections (162 mg) over 52 weeks. US of temporal (TAs), axillary (AAs) and subclavian (SAs) arteries was performed at baseline, on days 2-3, and at weeks 4, 8, 12, 24 and 52. The largest IMT of all segments and IMT at landmarks of AA/SA were recorded. IMT was scaled by mean normal values and averaged. Each segment was classified according to diagnostic cut-offs. RESULTS Of the 18 GCA patients, 16 patients had TA and 6 had extracranial large artery involvement. The IMT showed a sharp decline on day 2/3 in the TAs and AAs/SAs. In TAs, this was followed by an increase to baseline levels at week 4 and a subsequent slow decrease, which was paralleled by decreasing symptoms and achievement of clinical remission. The AAs/SAs showed a new signal of vasculitis at week 4 in three patients, with an IMT increase up to week 8. CONCLUSION Glucocorticoid pulse therapy induced a transient decrease of the IMT in TAs and AAs/SAs. Tocilizumab monotherapy resulted in a slow and steady decrease in IMT of the TAs and a smaller and delayed effect on the AAs/SAs. The data strongly support a remission-inducing effect of Tocilizumab and argue the case for US having an important role in monitoring disease activity in GCA. TRIAL REGISTRATION ClinicalTrials.gov, www.clinicaltrials.gov, NCT03745586.
Collapse
Affiliation(s)
- Luca Seitz
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| | - Lisa Christ
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| | - Godehard Scholz
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| | - Adela-Cristina Sarbu
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| | | | - Florian Kollert
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| | - Wolfgang A Schmidt
- Medical Centre for Rheumatology, Immanuel Krankenhaus Berlin, Berlin-Buch, Germany
| | - Stephan Reichenbach
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| | - Peter M Villiger
- Department of Rheumatology and Immunology, Inselspital, Bern University Hospital
| |
Collapse
|
26
|
Sebastian A, Tomelleri A, Dasgupta B. Current and innovative therapeutic strategies for the treatment of giant cell arteritis. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1932458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Alwin Sebastian
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff on sea, UK
| | - Alessandro Tomelleri
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff on sea, UK
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Bhaskar Dasgupta
- Rheumatology Department, Mid and South Essex University Hospitals NHS Foundation Trust, Southend University Hospital, Westcliff on sea, UK
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| |
Collapse
|